Identifying Vulnerable Patients at Heightened Risk for Medical Error

Elizabeth Andersson Mattox is the patient safety manager at the Veterans Administration Puget Sound Health Care System in the Seattle-Tacoma, Washington, area. She is pursuing a master of science degree in clinical informatics and patient-centered technology at the University of Washington School of Nursing, Seattle, Washington.

Practices, such as isolation precautions, that change workflow processes may have unintended consequences that increase patients’ risk.

The Institute of Medicine Report To Err Is Human,1 published in 2000, estimates that medical error contributes annually to 44 000 to 98 000 deaths in the United States among inpatients alone. Subsequent attempts to measure gains in the safety of health care delivery have not resulted in any significant progress.2,–5 Although several specific populations of patients have garnered increased attention, including intensive care unit (ICU) patients, most discussions on patient safety and medical error focus on understanding specific types of events (eg, medication error) or care processes (eg, hand offs) rather than on population characteristics. Patient- and population-level risk factors are relevant to understanding and preventing medical error.6,7